12.4 NOF + Analgesia

Question 1

An 80-year-old woman is admitted to your hospital having sustained a proximal femoral (neck of femur)
fracture in a fall.
a) How would you optimise this patient’s pain preoperatively? (5 marks)

Answer 1

> > Assess pain:
• Immediately on admission.
• 30 minutes after analgesia given.
• Hourly until settled on ward.
• As part of routine observations thereafter.

> > Analgesia to be given immediately
on admission with suspected hip
fracture, even if cognitively impaired.

> > Pain control should be
adequate to allow investigations.

> > Step-wise, multimodal analgesia:
• Paracetamol six hourly unless contraindicated.
• Opioid as necessary.
• Nerve block (e.g. fascia iliaca block)
by trained personnel.
• NSAID not recommended.

Question 2

b) You decide to perform a fascia iliaca compartment block for analgesia. What are the borders of the
fascia iliaca compartment (4 marks)

Answer 2

> > Anteriorly:
posterior surface of fascia iliaca.

> > Posteriorly:
anterior surface of
iliacus and psoas major muscles.

> > Medially:
origin of psoas major and vertebral column
from which it originates.

> > Laterally:
origin of iliacus muscle along
the inner aspect of the iliac crest.

Question 3

and which nerves are you attempting to block? (1 mark)
with FIB

Answer 3

> > Nerves: femoral, lateral femoral cutaneous, obturator

Question 4

c) Describe how you would perform this block using an ultrasound-guided technique. (10 marks)

NB consent has already been obtained; you also have adequate assistance, emergency equipment,
monitoring and venous access.

Answer 4

Patient supine.

> > Full asepsis: hat gown gloves mask,
0.5% chlorhexidine spray air dried,
transducer sleeve, sterile ultrasound gel.

> > 50-mm 22G block needle
unless patient habitus dictates otherwise.

> > High-frequency linear array probe,
positioned transversely just below the
inguinal ligament,
lateral to the femoral artery.
Identify the fascia iliaca,
fascia lata and iliacus muscle.

> > Inject a skin wheal of local anaesthetic
above where sartorius is visualised.

> > In plane needle insertion from lateral side,
tip under fascia iliaca.

> > Ensure negative aspiration then
inject 1–2 ml local anaesthetic;
ensure that the fascia iliaca is
seen lifting from the muscle,
spreading laterally and medially
towards the femoral nerve.

> > Continue to inject 30–40 ml
dilute local anaesthetic (e.g. 40 ml 0.25%
bupivacaine, ensure maximum of 2 mg/kg)
with repeated negative aspiration